Ohio Home Health Policy and Procedure Manual
For Ohio home health agencies licensed by the Ohio Department of Health (ODH) to provide skilled home health services, whether or not they are Medicare-certified. The manual has 59 policies and 48 forms, written to ORC Chapter 3740, OAC Chapter 3701-60 and the home health Conditions of Participation (42 CFR Part 484), with the Ohio Medicaid rules where your agency takes part. Each policy opens with a plain-English summary and names the rule it follows, and every one is filled in with your agency's details. You get Word and PDF files to keep, and your staff sign off on their phones.
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Ohio · Home health
59 policies written to the Ohio rules, with 48 forms. Every one is filled in with your agency's details.
- A plain-English summary first
- The rule each policy follows
- Word and PDF downloads, yours to keep
- Policies
- 59
- Forms
- 48
- Categories
- 14
- Policy Pack · required
- $950one-timeIncludes 90 days in the portal with Premium. To keep it open after that, Premium is $99 a month or $990 a year.
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3 free sample policies, shown in full for a sample agency.
OH-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Every patient and family may complain about any part of the Agency’s care or service without fear of reprisal. The Agency acknowledges each complaint within 5 and resolves it within 30, investigates, documents the complaint and its resolution, prevents retaliation, and tells patients how to complain to the Ohio Department of Health and other outside bodies. Complaints alleging abuse, neglect or misappropriation go straight to the safeguarding policies.
Read the full policy OH-HH-SG-01Free sample SafeguardingAbuse, Neglect, and Exploitation of Adults: Mandatory Reporting to Adult Protective Services
Every employee of a home health agency is a mandatory reporter under Ohio law: anyone with reasonable cause to believe an adult is being abused, neglected or exploited must immediately report it to the county department of job and family services (adult protective services). Sets out what to report, how to report at any hour, the extra routes for people with developmental disabilities and residents of long-term care facilities, waiver and ODA reporting, protection from retaliation, and what the Agency does after a report.
Read the full policy OH-HH-IC-01Free sample Infection controlInfection Prevention and Control Program
The Agency’s infection prevention and control program under 42 CFR §484.70: standard precautions on every visit, bag technique and equipment cleaning, transmission-based precautions, an agency-wide surveillance system with a method for identifying infection problems and a plan for improvement that is part of QAPI, reporting of communicable diseases to the local health district as Ohio’s reportable disease rules require, staff health, infection control education for staff, patients and caregivers, and monitoring of practice.
Read the full policy
Ohio rules
What Ohio's rules ask your policies to cover
- The basis for the license. The application shows Medicare certification, accreditation, ODA certification, or a notarized attestation that the agency meets the Medicare Conditions of Participation. ORC 3740.03(A)(1)(a); OAC 3701-60-03(A)(3)
- Renewal and changes. The license lasts three years. A renewal is on time only if filed at least ninety days before it expires, and ODH gets written notice of a change within ten days. ORC 3740.05; OAC 3701-60-03
- Background checks. A review of six databases, then a BCII criminal records check, with FBI information where the rule requires it. Employees are re-checked at least every five years. OAC 3701-60-05; OAC 3701-60-06
- Conditional employment. The BCII check is requested within five business days after conditional employment begins, and the job ends if results other than FBI are not received within sixty days. OAC 3701-60-07
- Adult abuse reporting. Every employee reports suspected abuse, neglect or exploitation of an adult aged 60 or older immediately to the county department of job and family services. ORC 5101.63
- Aide supervision. For patients who also get skilled care, a supervisory assessment of the aide at least every 14 days. For patients who get only aide services, an on-site registered nurse visit every 60 days. 42 CFR §484.80(h)
Questions a surveyor may ask
Every policy lists questions a surveyor may ask about it, so your staff can practice the answers. A few from this manual:
Show me your current skilled home health services license and the basis you used to obtain it.OH-HH-GOV-03Skilled Home Health Services License: Basis, Application, Renewal, Changes, and Enforcement
Which employees were hired conditionally, and when were their checks requested and received?OH-HH-HR-03Database Reviews, Criminal Records Checks, and Conditional Employment
Show me the supervisory assessments for this patient for the last 60 days.OH-HH-AID-02Home Health Aide Assignment, Care Instructions, and Supervision
Who in your agency is required to report suspected abuse of an adult, and to whom?OH-HH-SG-01Abuse, Neglect, and Exploitation of Adults: Mandatory Reporting to Adult Protective Services
Where does your notice give the state home health hotline, its hours, and the local Area Agency on Aging and other advocacy agencies?OH-HH-PR-01Patient Rights and Responsibilities
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Browse all 59 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 59 policies
Client rights5
OH-HH-CMP-01Free sample
Complaints and Grievances
Every patient and family may complain about any part of the Agency’s care or service without fear of reprisal. The Agency acknowledges each complaint within 5 and resolves it within 30, investigates, documents the complaint and its resolution, prevents retaliation, and tells patients how to complain to the Ohio Department of Health and other outside bodies. Complaints alleging abuse, neglect or misappropriation go straight to the safeguarding policies.
42 CFR §484.50(e)(1)
OH-HH-PR-01
Patient Rights and Responsibilities
Gives every patient, whatever the payer, the rights in 42 CFR §484.50: written notice of rights, responsibilities and the transfer and discharge policies at the initial evaluation visit before care, the Administrator’s complaint contact, the OASIS privacy notice, a signed acknowledgment, notice to a patient-selected representative within 4 business days, the Ohio Department of Health Home Health Hotline, local advocacy agencies, and immediate reporting of suspected abuse, neglect and exploitation under ORC 5101.63.
42 CFR §484.50
OH-HH-PR-02
Advance Directives and Do-Not-Resuscitate Orders
Gives every adult patient written information about Ohio advance directives before care is provided, records whether the patient has a living will declaration, durable power of attorney for health care or do-not-resuscitate (DNR) order, never conditions care on having one, explains how staff recognize valid Ohio DNR identification in the home and follow the DNR protocol, and sets out what to do in a cardiac or respiratory arrest.
42 CFR §489.102
OH-HH-PR-03
Service Agreement, Informed Consent, and Disclosure of Charges
Sets out the written service agreement each patient signs before care begins, informed consent and the right to refuse, consent to release information, the oral and written explanation of expected payment and charges before care is initiated, advance written notice before possibly non-covered care and before care is reduced or ended (with the Medicare notices for certified agencies), and the Ohio Medicaid rule that Medicaid payment is payment in full.
42 CFR §484.50(c)(7)
OH-HH-PR-04
Language Access, Accessibility, and Nondiscrimination
Provides free, accurate and timely language assistance and auxiliary aids to every patient and representative who needs them; identifies needs at the first contact; uses qualified interpreters and translators and never minors except in an emergency; gives the notices of nondiscrimination and of available language help where Section 1557 applies; and handles discrimination complaints.
42 CFR §484.50(f)
Service delivery10
OH-HH-ADM-01
Referral Intake, Acceptance to Service, and Public Information About Services
The Agency’s patient acceptance-to-service policy under 42 CFR §484.105(i): how referrals are received and screened, the criteria applied consistently to every prospective patient (anticipated needs, case load and case mix, staffing levels, staff skills and competencies), how decisions are made and communicated, the non-admission log, the accurate public information about services and limitations, and the annual review.
42 CFR §484.105(i)
OH-HH-ADM-02
Initiation of Care and the Initial Assessment Visit
Sets the time frame and content of the initial assessment visit: a registered nurse (or the therapist when therapy is the only service ordered) visits within 48 hours of referral, within 48 hours of the patient’s return home, or on the practitioner-ordered start of care date; gives the rights and other notices before care; assesses immediate needs and, for Medicare patients, eligibility and homebound status; and obtains practitioner approval for changes to the referral orders.
42 CFR §484.55(a)
OH-HH-ADM-03
Eligibility, Certification, Face-to-Face Encounter, and Ohio Medicaid Certificate of Medical Necessity
Sets out how the Agency confirms that each patient qualifies for the services billed: for Medicare, the practitioner’s certification, the face-to-face encounter no more than 90 days before or within 30 days after the start of care, homebound status and skilled need, recertification at least every 60 days, and the bar on certifying practitioners with a financial relationship; for Ohio Medicaid, the face-to-face encounter documented on the ODM 07137 Certificate of Medical Necessity, the part-time or intermittent hour limits, the post-hospital and increased-services rules, and the plan of care and waiver services plan.
42 CFR §424.22
OH-HH-CC-01
Coordination of Care and Communication with Practitioners
Makes sure every discipline, contractor and practitioner involved in a patient’s care works from one integrated plan: the clinical manager coordinates care; the Agency communicates with all practitioners and integrates their orders; staff report changes; case conferences are held; the patient and caregivers are involved and educated; each patient receives written visit, medication and treatment instructions with the clinical manager’s contact details; and waiver case managers are kept informed.
42 CFR §484.60(d)
OH-HH-CC-02
After-Hours Care, On-Call, and Back-Up Staffing
Keeps the Administrator (or the pre-designated alternate) and a clinical manager available during all operating hours, runs an on-call system so that patients can reach a registered nurse at any hour, sets how after-hours calls are handled, and keeps back-up staff available so that scheduled visits are made when regularly scheduled staff cannot make them, including the back-up plan and case manager notices for waiver patients.
42 CFR §484.105(b)(3)
OH-HH-CS-01
Scope of Home Health Services and Services Offered
Defines the home health services Sample Agency, LLC provides under its Ohio skilled home health services license, using the Ohio statutory definitions and the federal requirement to offer skilled nursing and at least one other therapeutic service, at least one of them directly. Sets out where services are given, what the Agency does not provide, how services under arrangement fit in, the public information the Agency keeps about its services and their limits, and the steps for adding, changing or stopping a service, including written notice to the Ohio Department of Health within ten days.
42 CFR §484.105(f)
OH-HH-CS-04
Laboratory Services and Waived Testing
Explains when the Agency is doing laboratory testing that needs a CLIA certificate and when it is only helping a patient test with the patient’s own FDA-cleared device; limits Agency testing to waived tests under a current CLIA certificate of waiver, performed by trained staff following the manufacturer’s instructions; and sets the steps for collecting and sending specimens to certified referral laboratories and reporting results.
42 CFR §484.100(c)
OH-HH-DC-01
Discharge Planning, Transfer Summaries, and Transitions of Care
Runs an effective discharge planning process from the start of care: the patient’s goals and preferences guide planning; patients transferring to another home health agency or discharged to a skilled nursing facility, inpatient rehabilitation facility or long-term care hospital are helped to choose a provider using quality and resource use data; necessary medical information goes to the receiving provider; and the discharge summary is sent within 5 business days of discharge and the transfer summary within 2 business days of a planned transfer or of learning of an unplanned one.
42 CFR §484.58
OH-HH-DC-02
Transfer and Discharge Notices, Including Discharge for Cause
Limits transfer and discharge to the seven grounds in 42 CFR §484.50(d), sets who decides, gives the patient written notice with the advance notice each payer requires (the Medicare termination notice no later than 2 days before services end if the Agency is Medicare-certified; for Ohio Medicaid at least thirty days before the last date of service unless an exception applies; for ODM-administered waiver services thirty calendar days, or ten days in listed cases), explains the Medicare expedited determination, and sets the steps that must come before a discharge for cause.
42 CFR §484.50(d)
OH-HH-WVR-01
Ohio Medicaid Waiver Services: Personal Care Aide and Waiver Nursing
Applies when the Agency provides personal care aide or waiver nursing services to individuals enrolled on an Ohio Department of Medicaid-administered waiver (the Ohio Home Care Waiver or the MyCare Ohio waiver). Covers the waiver provider conditions of participation and prohibited conduct, individual rights, the scope of personal care aide services, aide qualifications (an ODH-approved or Medicare aide competency program, hands-on first aid certification, and twelve hours of in-service continuing education in each twelve-month period), RN supervision (an initial face-to-face home visit, a face-to-face visit at least every sixty days while the aide is present and providing care, and in-person RN assessment visits at least twice a year), clinical records, waiver nursing, incident management, EVV, and notice before ending services.
OAC 5160-46-04
Patient care3
OH-HH-ASM-01
Comprehensive Assessment and Reassessment
Every patient receives a patient-specific comprehensive assessment, completed by a registered nurse (or the therapist when therapy is the only service ordered) no later than 5 calendar days after the start of care, covering the content in 42 CFR §484.55(c) including a drug regimen review and the current OASIS items, and updated in the last 5 days of every 60 days, within 48 hours of return home from a hospital stay of 24 hours or more, at a major change and at discharge.
42 CFR §484.55
OH-HH-ASM-02
OASIS Data Collection, Accuracy, and Transmission
Collects the OASIS items as part of every comprehensive assessment; makes sure the data accurately reflect the patient’s status; and, if the Agency is Medicare-certified, encodes and transmits each completed OASIS assessment to the CMS system within 30 days of completing the assessment, for every patient CMS requires (since July 1, 2025, patients of any payer who are not exempt), using compliant software, secure transmission and the CMS branch identification number, while keeping patient-identifiable OASIS information confidential.
42 CFR §484.45
OH-HH-CP-01
Individualized Plan of Care
Every patient receives services written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, is established, periodically reviewed and signed by a doctor of medicine, osteopathy or podiatry or an allowed practitioner, contains every item in 42 CFR §484.60(a)(2), records all orders, and is reviewed and revised at least once every 60 days, with prompt alerts to the practitioner and communication of every revision; Medicare plan of care rules and Ohio Medicaid’s rule that services not on the plan are not reimbursable also apply.
42 CFR §484.60(a)
Clinical tasks8
OH-HH-AID-01
Home Health Aide Training, Competency Evaluation, and Registry Checks
Sets out who may work as a home health aide for the Agency: the four federal qualification routes, the 24-month lapse rule, the Ohio nurse aide registry check at hire, the content and length of any aide training program the Agency runs (at least 75 hours, with at least 16 hours of classroom training before at least 16 hours of supervised practical training), the RN-led competency evaluation every aide passes before furnishing services, the eligibility limits on agencies that train or evaluate aides, training for extra skills, at least 12 hours of in-service training in every 12-month period, and checks on aides furnished under arrangement.
42 CFR §484.80(a)
OH-HH-AID-02
Home Health Aide Assignment, Care Instructions, and Supervision
Sets out how a registered nurse or therapist assigns each aide to a specific patient with written patient care instructions, what aides do and do not do under Ohio and federal rules, how aides report changes, and the federal supervisory visit schedule: for patients receiving skilled services, a supervisory assessment at least every 14 days (with at most one virtual assessment per patient in a 60-day episode) and an annual on-site observation of each aide; for patients receiving aide services only, an onsite visit by the RN every 60 days and a semi-annual on-site observation of each aide. Also covers retraining when a deficiency is verified and supervision of aides under arrangement.
42 CFR §484.80(g)
OH-HH-CS-02
Skilled Nursing Services and Ohio Nursing Practice
Sets out who may furnish skilled nursing for the Agency, what registered nurses and licensed practical nurses do, how nursing is supervised, the Ohio nursing practice limits that apply (practice within an Ohio license, the Board of Nursing’s standards of practice, LPN practice at the direction of a registered nurse, and the tasks Ohio Medicaid reserves to registered nurses), and how nurses document visits, report changes, teach, and keep their skills current.
42 CFR §484.75
OH-HH-CS-03
Therapy and Medical Social Services
Sets out who may provide physical therapy, occupational therapy, speech-language pathology and medical social services for the Agency, the federal qualifications and Ohio licensing boards for each discipline, what therapists and social workers do (including therapy-only assessments and aide instructions), how therapy assistants and social work assistants are supervised, and how Ohio Medicaid limits on therapy affect care.
42 CFR §484.75
OH-HH-CS-05
Death in the Home and Pronouncement of Death
Tells staff what to do when a patient dies or appears to have died at home: when to start CPR and call 911, how to recognize valid Ohio do-not-resuscitate identification, who may pronounce death in Ohio (the Agency’s registered nurses do not, unless the governing body has adopted a procedure after confirming the conditions in ORC 4723.36 are met), when a health care worker must immediately notify the coroner under ORC 313.12, how the attending physician and funeral director handle the death certificate, and what the office does next.
ORC 4723.36
OH-HH-DEL-01
Delegation of Nursing Tasks to Unlicensed Staff
Applies the Ohio Board of Nursing delegation rules (OAC Chapter 4723-13) to the Agency: only a licensed nurse may delegate a nursing task, an LPN only at the direction of an RN; the determinations and evaluation the nurse must complete before delegating; the short list of medications that may be delegated; no re-delegation; and, because the Agency’s substantial purpose is the provision of health care services, on-site direct supervision by the delegating nurse of every delegated task. Explains how delegation differs from assigning aide services and from helping a patient self-administer medication.
OAC 4723-13-05
OH-HH-MED-01
Medication Management, Drug Regimen Review, and Help with Self-Administration
Covers the medication profile, the drug regimen review in every comprehensive assessment and update, medication administration by Agency nurses only as ordered, the limited help aides may give with self-administered medications under Ohio rules, the written medication schedule every patient receives, adverse reactions and medication errors, the influenza and pneumococcal vaccine protocol, and teaching, safe storage and disposal in the home.
42 CFR §484.55(c)(5)
OH-HH-ORD-01
Practitioner Orders and Verbal Orders
Sets out who may order care for Agency patients, the kinds of orders the Agency accepts, who may accept a verbal order (registered nurses, and therapists for their own discipline), how a verbal order is read back, documented, signed, dated and timed and recorded in the plan of care, how it is sent to the practitioner for authentication and dating within the Agency’s own time frame of 14 days, how unsigned orders are tracked, and the Medicare and Ohio Medicaid rule that signed orders must be in the record before the Agency bills.
42 CFR §484.60(b)
Safeguarding3
OH-HH-SG-01Free sample
Abuse, Neglect, and Exploitation of Adults: Mandatory Reporting to Adult Protective Services
Every employee of a home health agency is a mandatory reporter under Ohio law: anyone with reasonable cause to believe an adult is being abused, neglected or exploited must immediately report it to the county department of job and family services (adult protective services). Sets out what to report, how to report at any hour, the extra routes for people with developmental disabilities and residents of long-term care facilities, waiver and ODA reporting, protection from retaliation, and what the Agency does after a report.
ORC 5101.63
OH-HH-SG-02
Child Abuse and Neglect: Mandated Reporting
Every employee of a home health agency is a "health care professional" and a mandated reporter under Ohio law. Anyone who knows or has reasonable cause to suspect that a child under 18, or a person under 21 with a developmental disability or physical impairment, has suffered or faces a threat of abuse or neglect must immediately report it to the public children services agency or a peace officer in the county. Sets out how to report, protection for reporters, the penalty for not reporting, and what the Agency does next.
ORC 2151.421
OH-HH-SG-03
Allegations Against Staff: Protection, Investigation, and Reporting
When anyone alleges that a person furnishing services on the Agency’s behalf mistreated, neglected or abused a patient, caused an injury of unknown source, or misappropriated a patient’s property, the Agency protects the patient at once, makes every outside report the law requires, removes the staff member from patient contact while it investigates, prevents retaliation, investigates and documents the allegation and its resolution, and acts on the findings, including reports to licensing boards.
42 CFR §484.50(e)
Infection control3
OH-HH-IC-01Free sample
Infection Prevention and Control Program
The Agency’s infection prevention and control program under 42 CFR §484.70: standard precautions on every visit, bag technique and equipment cleaning, transmission-based precautions, an agency-wide surveillance system with a method for identifying infection problems and a plan for improvement that is part of QAPI, reporting of communicable diseases to the local health district as Ohio’s reportable disease rules require, staff health, infection control education for staff, patients and caregivers, and monitoring of practice.
42 CFR §484.70
OH-HH-IC-02
Bloodborne Pathogens Exposure Control, Sharps, and Infectious Waste
The Agency’s written Exposure Control Plan under the OSHA bloodborne pathogens standard, which applies directly to the Agency in Ohio: which jobs have occupational exposure, engineering and work practice controls, protective equipment, sharps containers, the handling of infectious waste staff generate in homes, instructions to patients and families who use sharps, hepatitis B vaccination within 10 working days of initial assignment, post-exposure evaluation and the written opinion within 15 days, labels, training at assignment and at least annually, the annual plan review with frontline input, and records (medical records for the duration of employment plus 30 years, training records for 3 years, and the sharps injury log).
29 CFR §1910.1030
OH-HH-IC-03
Employee Health Screening, Immunizations, and Tuberculosis Testing
Sets the Agency’s own employee health program, since neither Ohio’s home health rules nor 42 CFR Part 484 prescribe health screening or tuberculosis testing for home health staff: a health screening at hire, tuberculosis screening that follows the 2019 CDC and National Tuberculosis Controllers Association recommendations as guidance (baseline risk assessment, symptom screen and TB test at hire; no routine annual testing without known exposure or ongoing transmission; annual TB education), recommended immunizations and the yearly influenza vaccine offer, hepatitis B vaccination under OSHA, respirator medical evaluation and fit testing where respirators are used, work restrictions for illness, and confidential employee medical records.
42 CFR §484.70
Emergency preparedness1
Records2
OH-HH-REC-01
Clinical Records: Content, Authentication, Retention, and Protection
Sets what goes in every patient’s clinical record, how entries are written, authenticated, dated, timed and corrected, how paper and electronic records are protected in the office, in the car and in the home, where an out-of-state agency keeps Ohio records, and how long records are kept: the longest of the federal five years after discharge, Ohio Medicaid’s six years from payment or until an audit closes, and the Agency’s own seven-year standard.
42 CFR §484.110
OH-HH-REC-02
Patient Access to Records, Copies, and Release of Information
Gives patients and their representatives access to their records: the patient’s copy is free and available at the next home visit or within 4 business days, whichever comes first; requests are made on a signed form dated within one year as Ohio law requires; identity is checked; Ohio’s fee limits apply to anyone else; and records go to other people only with a valid authorization or as the law allows, with Ohio’s extra protection for HIV information and Medicaid recipient information.
ORC 3701.74
Privacy3
OH-HH-PRV-01
HIPAA Privacy and Ohio Confidentiality Laws
Protects the privacy of patients’ health information under the HIPAA Privacy Rule, the home health Conditions of Participation and Ohio’s confidentiality laws for HIV test results and diagnoses and for Medicaid recipient information. Names the Privacy Official, sets out when information may be shared, lists patients’ privacy rights and the time frames for each, keeps OASIS data confidential, and requires a Notice of Privacy Practices, training, sanctions and business associate agreements.
45 CFR §164.530
OH-HH-PRV-02
HIPAA Security
Puts in place the HIPAA Security Rule’s administrative, physical and technical safeguards for electronic patient information, with particular attention to the laptops, tablets and phones clinicians carry into patients’ homes and the electronic visit verification apps Ohio Medicaid requires: risk analysis and risk management, access control, device rules, encryption, OASIS transmission, security incidents, backup and contingency planning, business associates and disposal.
45 CFR §164.308
OH-HH-PRV-03
Breach Notification
Sets out what the Agency does when patient information may have been lost, stolen, sent to the wrong person or otherwise compromised: same-day internal reporting, containment, a documented four-factor risk assessment, and every notice HIPAA requires (individuals within 60 calendar days of discovery, the HHS Secretary, and the media for large breaches). Explains that Ohio’s data breach notice law does not apply to a HIPAA covered entity, so HIPAA governs.
45 CFR §164.404
Human resources6
OH-HH-HR-01
Personnel Policies, Qualifications, Orientation, In-Service Education, and Evaluation
Sets the Agency’s written personnel policies: job descriptions, the federal qualifications for each discipline, Ohio licensure, the hiring steps, orientation before the first patient visit, the training required by rule (aide in-service, bloodborne pathogens, emergency preparedness, infection control), competency checks and annual performance evaluation.
42 CFR §484.115
OH-HH-HR-02
Personnel Records
Lists what goes in each personnel file, keeps criminal records check reports and disqualifying database results sealed in or separate from the file, keeps employee medical records separate, limits who may see the files, keeps the background check roster available to the Ohio Department of Health, and sets retention periods.
OAC 3701-60-10(B)
OH-HH-HR-03
Database Reviews, Criminal Records Checks, and Conditional Employment
The Agency’s written criminal records check policy, filed with its license application: who is covered, the notice given to applicants, the six-database review that comes first, the BCII (and where needed FBI) criminal records check with fingerprints, conditional employment with the five-business-day and sixty-day limits, re-checks every five years, and the confidential roster kept for the Ohio Department of Health.
ORC 3740.11
OH-HH-HR-04
Disqualifying Offenses, Exclusionary Periods, Certificates, and Pardons
Tells the Administrator how to decide whether a person whose criminal records check shows an offense may work in direct care: the offenses listed in OAC 3701-60-08, the five exclusionary tiers in OAC 3701-60-09 counted from full discharge from imprisonment, probation or parole, the longer periods for multiple offenses, and the effect of certificates of qualification for employment, certificates of achievement and employability, and pardons.
OAC 3701-60-09
OH-HH-HR-05
Professional License Verification and Reporting to Ohio Licensing Boards
Requires the Agency to verify every professional license and certification on the issuing board’s official system before a person starts, at each renewal and when concerns arise; to remove anyone whose license lapses; and to report a nurse to the Ohio Board of Nursing when the Agency knows or has reason to believe the nurse engaged in conduct that would be grounds for discipline.
ORC 4723.34
OH-HH-HR-06
Staff Safety in the Home and Workplace Violence Prevention
Protects staff who work alone in patients’ homes: safety screening at referral and at the first visit, visit tracking and check-in, personal safety practices, the right to leave an unsafe home after making the patient as safe as possible and calling the supervisor, response to aggression, harassment and workplace violence (including discharge for cause and the Ohio Medicaid notice exceptions), driving and weather, safe patient handling, other hazards in homes, and incident reporting, including reporting a work-related death to OSHA within 8 hours and an in-patient hospitalization, amputation or loss of an eye within 24 hours.
29 U.S.C. §654(a)(1)
Governance6
OH-HH-GOV-01
Governing Body, Organization, and Lines of Authority
Names the governing body as the body with full legal authority for the Agency, sets its duties and meetings, requires a written organizational chart showing lines of authority down to the care given in the patient’s home, keeps a register of owners, controlling interests, officers and the statutory agent that is reported to the Ohio Department of Health within ten days of any change, and forbids handing administrative or supervisory functions to another organization.
42 CFR §484.105(a)
OH-HH-GOV-02
Administrator, Alternate Administrator, and Clinical Manager
Sets the qualifications, duties and availability of the Administrator, the pre-designated alternate who acts when the Administrator is not available, and the clinical manager who oversees all patient care services and personnel, and records each appointment and written authorization on one designation form.
42 CFR §484.105(b)
OH-HH-GOV-03
Skilled Home Health Services License: Basis, Application, Renewal, Changes, and Enforcement
Explains why the Agency must hold an Ohio skilled home health services license, the basis on which it holds it, what the application contains, how and when the license is renewed, which changes must be reported to the Ohio Department of Health within ten days, how the Agency answers requests for information and survey findings, and what happens if the license is denied, suspended or revoked.
ORC 3740.02(A)(1)
OH-HH-GOV-04
Operating Location, Branch Offices, Service Area, and Out-of-State Agencies
Defines the Agency’s operating location and branch offices, makes the parent responsible for direct support and administrative control of every branch, keeps a register of locations and the counties served, requires notice before a location or the service area changes, and requires an agency based outside Ohio to keep an Ohio administrative office holding all Ohio patients’ clinical records.
42 CFR §484.105(d)
OH-HH-GOV-05
Services Under Arrangement, Contracted Staff, and Employment Services
Requires a written agreement for every service the Agency furnishes under arrangement, keeps the Agency responsible for those services and the way they are furnished, bars arrangements with excluded or revoked providers, and sets the rules for staff referred by an employment service, including when the service may supply the database review and criminal records check.
42 CFR §484.105(e)
OH-HH-GOV-06
Agency Closure, Change of Ownership, and Continuity of Records
Sets out what the Agency does if it plans to close, stop a service, or change ownership: deciding and notifying regulators and payers, giving patients notice and arranging safe transfers, and making sure clinical, Medicaid and personnel records stay available for the full retention period after the Agency stops operating.
42 CFR §484.110(c)(2)
Quality3
OH-HH-QA-01
Quality Assessment and Performance Improvement (QAPI)
Sets up the Agency’s data-driven quality assessment and performance improvement (QAPI) program for every service, including services under arrangement: the governing body’s duties, the QAPI committee, the quality indicators and data the governing body approves, how problems are chosen and corrected, performance improvement projects, infection control within QAPI, the handling of fraud or waste findings, and an annual report to the governing body.
42 CFR §484.65
OH-HH-QA-02
Incident Reporting, Investigation, and Ohio Medicaid Waiver Incident Management
Requires every incident, adverse event and near miss to be reported inside the Agency the same day on Form OH-HH-QA-02-A, investigated, and analyzed through QAPI. Lists the outside reports that may be required, and for patients on an Ohio Medicaid waiver or in a Medicaid managed care plan sets out the incident management rule: immediate action, and a report to the case management agency or plan immediately and no later than one business day after discovery.
42 CFR §484.65(c)(2)
OH-HH-QA-03
Home Health Quality Reporting, HHCAHPS, and Survey Readiness
For a Medicare-certified agency, meets the Home Health Quality Reporting Program: OASIS and other data submitted as CMS specifies, the 90 percent OASIS submission threshold that avoids a 2-percentage-point payment reduction, HHCAHPS through an approved independent vendor (or the annual patient count for an exemption), and the exception and reconsideration routes. For every agency, sets out how it stays ready for Ohio Department of Health licensing reviews and federal and accreditation surveys, and how it answers a statement of deficiencies.
42 CFR §484.245
Business4
OH-HH-BUS-01
Overall Plan, Annual Operating Budget, Capital Expenditure Plan, and Insurance
Requires an overall plan and a budget prepared under the direction of the governing body, with an annual operating budget and a capital expenditure plan for at least three years, reviewed and updated at least annually; and keeps the Agency’s surety bond, workers’ compensation coverage, insurance and business records in order.
42 CFR §484.105(h)
OH-HH-BUS-02
Charges, Billing, Claims, and Overpayments
Sets the rules for charges and claims: bill only for services actually provided, documented and ordered; complete documentation and resolve electronic visit verification exceptions before billing Ohio Medicaid; accept Medicaid payment as payment in full; tell patients about charges before care starts; and report and return overpayments within the federal deadline.
42 CFR §401.305
OH-HH-BUS-03
Electronic Visit Verification for Ohio Medicaid Home Health Services
Requires every Ohio Medicaid home health aide, nursing and therapy visit (and waiver personal care aide and waiver nursing visit) to be verified through electronic visit verification at the visit, using the state Sandata system or an approved alternate, with manual entry only as a last resort, signed and yearly-renewed patient consent before any GPS function is used, accurate data, and every exception resolved before the claim is billed.
OAC 5160-32-02
OH-HH-BUS-04
Ohio Medicaid Provider Agreement, Enrollment, and Program Integrity
Sets out the duties the Agency accepts when it signs an Ohio Medicaid provider agreement: who may provide Medicaid home health, keeping enrollment, ownership and location information current within thirty days, screening for sanctioned persons, protecting recipient information, cooperating with reviews, site visits and audits, and responding to enrollment moratoria and payment suspensions.
OAC 5160-1-17.2
Ethics2
OH-HH-ETH-01
Compliance Program, Exclusion Screening, and Fraud Prevention
Sets up the Agency’s compliance program on the seven elements in the federal Office of Inspector General’s guidance: written standards, a compliance lead, training, ways to report concerns without fear of retaliation, consistent discipline, auditing and monitoring including monthly exclusion screening, and prompt response and correction, with reports to the governing body.
42 CFR §1001.1901
OH-HH-ETH-02
Referrals, Kickbacks, Patient Inducements, and Marketing
Forbids paying or receiving anything of value for referrals, sets the conditions for any financial arrangement with physicians and other referral sources, limits gifts to patients, and requires all marketing to be accurate and limited to services the Agency is licensed for and provides.
42 U.S.C. §1320a-7b(b)
Questions
Questions about this manual
Is this the right manual for my license?
It is for agencies with an ODH skilled home health services license. Agencies licensed only for nonmedical home health services need the Ohio home care manual, and hospice care programs need the Ohio hospice manual.
We are not Medicare-certified. Does the manual still fit?
Yes. To hold the skilled license, an agency shows Medicare certification, accreditation, ODA certification or a notarized attestation that it meets the Medicare Conditions of Participation (ORC 3740.03(A)(1)(a)). So the policies apply 42 CFR Part 484 to every patient and mark the duties that apply only to Medicare-certified agencies, such as OASIS transmission.
Does Ohio have its own home health care rules?
Ohio's licensing rules (OAC 3701-60) cover licensing and background checks. They set no rules for patient rights, complaints, infection control, emergency preparedness or aide training, so the policies follow the federal Conditions of Participation there. Ohio has no certificate of need for home health agencies.
What do the 59 policies cover?
Client rights (5), service delivery (10), patient care (3), clinical tasks (8), safeguarding (3), infection control (3), emergency preparedness (1), records (2), privacy (3), human resources (6), governance (6), quality (3), business (4) and ethics (2).
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